Brigadier-General Jean-Robert Bernier, who took over as Surgeon General and Director General of the Canadian Forces Health Services Group (CFHSG) in July 2012, sat down with Frontline to discuss priorities and responsibilities. The interview covered such a wide range of topics that we will publish it in two parts. The first tackles mental health issues and the next will shed light on the complexities of managing such a large and diverse medical organization, with its unique ratio of challenges versus civilian requirements.

To set the stage, BGen Bernier reminds us that military troops “can be ordered into situations where they may lose their lives for the protection of other Canadians. It is very gratifying for us to see how much Canadian society, our political leaders, and our military chain of command takes the responsibility for care ­seriously.”

Evidence clearly shows that Medical Services Group makes a valiant effort to prepare members of the Canadian Armed Forces for the stresses of combat and the ethical conflicts that may present themselves as a result of cultural differences that we are not exposed to here in North America. Are these efforts enough? Media reports have revealed that some individuals may not have been exposed to the same high level of education that the medical establishment believes is being presented to troops. However, some also admit to not paying enough attention early on, believing themselves to be invincible.

Although every case of mental illness varies greatly, the Medical Services Group continues to review and reform its policies and procedures, attempting to provide the optimum care to each individual.

Of the medical community in general, BGen Bernier says “We analyze everything.” And as for the CAF in particular, he says “we try to guide, with objective measures, all of our policies and programs through clinical practices. We stay on top of that through links to every organization that can contribute to military health research and best practices – everything we do is focused on obtaining the best possible evidence and research supporting our ­practices.”

The first step in trying to mitigate against mental health problems is during recruitment. CF recruiters try to screen out conditions that may predispose a person to greater risk of negative stress response. According to BGen Bernier, a detailed social and medical screening is completed pre-deployment. Mental health services are also provided in theatre during deployment. Afterwards, there is also an enhanced post-deployment screening, which he describes as “fairly thorough.” Bernier also says that ongoing periodic health assessments follow throughout the course of a person’s career, including all stages of leadership training.

The Road to Mental Readiness, a program developed by the Medical Services Group, was based on sports psychology. It aims to increase confidence and resiliency, provide skills to deal with the stresses of military operations, plus increase the willingness to seek care if they do develop abnormal symptoms and signs as a result of their experiences. Before deployment, an intense work readiness curriculum dissects the impacts of stress and its relationship to performance. Bernier explains that the skills taught in this program are based on tactics used by sports psychologists to help high level athletes deal with the stresses of intense athletic competition and to enhance success – things like tactical breathing and visualization and other techniques that help people become resilient and better able to deal with stresses. The education portion helps them identify signs that are worrisome (when actions or emotions exceed the normal reaction to stress). The intent is to help people recognize the signals of when they may need help.

After a major deployment, says Bernier, “we’re supposed to send people to a third location (not in Canada) for decompression for several days, where they can unwind. During that period, they receive briefings on the kinds of things to expect, to get them ready for reintegration into Canada and give them the opportunity to talk to mental health professionals and, if they have been identified as needing some kind of follow up for mental health, a referral will already be set up by the time they get back to Canada.”

Bernier explains that regular periodic health assessments continue to take place throughout the course of a person’s career. These include “all kinds of screening” for mental health conditions, including addictions, and he says there are “all kinds of programs to respond, to provide treatment, intervention, and education.”

Stress is not the only cause of mental health injuries. “We know there is complete interdependency between mental and physical health. Mental health issues can lead to adverse physical symptoms and illness, and physical injury and illness can lead to mental health problems – especially after a serious injury – and a traumatic brain injury can have symptoms that are similar to PTSD and other mental health disorders. Experiences like a blast injury can also potentially cause mental harm, so yes we monitor for that, we have a ­complete process for treatment and evaluation of physical injuries based on the best evidence.”

Undergoing resiliency training before deployment is widely acknowledged now as critical to recovering from a mental illness if one develops. The CAF Health Services has “initiated a large randomized control trial, the gold standard of medical evidence, in partnership with Defence Research and Development Canada and the Canadian Forces Language and Recruit School – and that program includes psychological fitness markers, biological markers and performance measurements, to try to validate the effect of our Road to Mental Readiness program.” Bernier says the self-reported pre and post surveys are “showing decreased stigma, increased efficacy in dealing with mental health issues, increased confidence, increased ability to recognize abnormal signs and symptoms that are beyond the normal response to stress, and increased capability to do safe self-care.” He referenced another study that indicates stigma is very low in the armed forces, and what stigma remains is mainly self-imposed by the individual. “Some of them think they should be able to ‘tough it out’ – our biggest problem is self-imposed stigma and self-medicating (with alcohol or other drugs),” he notes.

Stigma & Leadership
The leadership of the armed forces appears to be committed to eliminating the stigma of mental injuries and very much understands the impact on operational readiness and operational capability, as well as the ethical responsibility of looking after troops.

With its huge effort to reduce the stigma of mental health injuries, many see the military as being much more successful than civilian society in changing that culture of understanding. “Mental health conditions are well accepted as just another injury, and so we call them Operational Stress Injuries.” As an example of this change in culture, Bernier notes that the Sacrifice Medal, which is given to individuals who are killed or wounded as a result of military service, is also awarded to those who have suffered mental health conditions as a result of the stresses from combat and military operations.
“Compared to our allies and certainly compared to the general population we have a lower level of stigma in the Canadian Forces, and that’s a result of not just our efforts but leadership efforts,” says Bernier. “We can set up all the programs, but unless the leadership embraces it, enforces it, and sets the cultural tone, then it doesn’t get implemented. Our leaders, they get it. The military leaders of the Canadian Armed Forces are renowned around the world, in NATO certainly, for the degree of resources and the attention they pay to looking after the welfare and health of the troops.”

Measurement
Canadian Armed Forces Ombudsman Pierre Daigle is very concerned about a lack of measurement across mental health issues: the number of cases coming in, outcomes of treatment, among others. Is the CF doing an adequate job of measurement?

“We very much welcome the Om­budsman’s focus on the issue and his recommendations,” responds BGen Bernier, “but like all public health authorities, point data based on a specific number of cases is only good for that moment in time. Like all public health agencies, we need much broader reliable measures over a course of time that will give us a generally applicable finding, because there are so many confounding variables that can lead to a high or a low in a PTSD database (for example how many people presented for care that day).” He explains that database numbers are only useful if analyzed on a long-term scale because daily statistics can be skewed by so many variables. “If there’s an operation going on, many people won’t present even though they have PTSD symptoms, because they want to go on operation. So it would not be a reliable measure to have a spot database that would give us an actual number at the moment of specific cases, it won’t contribute usefully to our modification of programs, it won’t be a useful guide to determine what policy changes or resource requirements are necessary. We use much more effective measures, broad studies, such as the Canadian community health survey of 2002/03 by Statistics Canada. We’re repeating the same study at this moment that will give us a much better, stable and universal picture of the state of mental health, and will help guide resource allocations – determining whether we need additional resources, a different mix of resources, where the problems are specifically, what policy changes or changes to the enhanced post deployment screening analysis may be necessary, and many other things.”

The Health Services Group has just begun a health and lifestyle survey it conducts every four years. “Big global studies that look at everything are far more useful and far more reliable in intelligently guiding the modification of policy, programs, and resources than a PTSD database that gives us a day to day number of cases. We will get to that point eventually with the Canadian Forces Health Information System; one of the applications will eventually allow us to enter key variables, and we’ll be able to push a button and it will spit out the number of cases that momentarily fit the variables we punched in. We study the mental health of our troops more than any other employer in Canada, and we can safely say that the Canadian Forces has a better understanding and knowledge of the mental health status and the requirements for its population than any other mental health jurisdiction or employer in Canada.”

Social Networks
Many other organizations are also dedicated to the rehabilitation of injured soldiers. The Operational Stress Injury Social Support (OSISS) group is a social support network that is run by the Director General of Morale and Welfare Services, under his Director of Casualty Support Management. Although not a part of Health Services, Bernier says “it helps us a lot and we’re strong champions of social supports because of that stigma, particularly knowing that it’s the individuals themselves who self-impose the stigma of not wanting to present for care because they think they can deal with it themselves. We rely very much on the family and friends and social services to help identify to them that they need help. The OSISS helps convince them, by virtue of the members having themselves suffered a mental health condition, that there is help available, to help reduce the stigma, and to help get them the care. That’s the most important thing, the earlier we get them into care the better to maximize their chances of either full recovery or at least to recover enough that they can continue to live a normal, fruitful, productive life. Rather than white-coated physicians, OSISS members are their peers and may be in the best position to convince individuals that they can get help, that there is a light at the end of the tunnel if they do present for care. It’s critically important to us that there is a social support system of some sort.”

Joint Personnel Support Unit
Currently, there is a lot of media attention on the JPSU, which is an administrative unit also run by the Director of Casualty Support Management to consolidate and coordinate support to patients (it does not provide treatment).

Stood up in 2009, under what was then called the CF Personnel Support Agency and now Morale and Welfare Services, the JPSU has centers across the country as an extra measure to assist mentally and physically injured troops consolidate the many elements of support available to them.
Neither the JPSU or its many subordinate base/wing IPSCs have any involvement in the treatment of patients, nor does its staff have the qualifications to do so. The health care of ill and injured is entirely and exclusively the mandate of CFHSG.

Although not part of the CF Health Services Group, Bernier is well aware of the advantages provided by the JPSU’s eight regional units which oversee 24 IPSCs (Integrated Personnel Support Centres) across Canada. “The fear of being released from the Armed Forces by virtue of no longer being capable of fulfilling their military functions, is the concern that may lead some individuals not to present for care, and so the JPSU is trying to get them back to duty.” Getting posted to a JPSU takes the injured member out of their previous Unit, and FrontLine wondered if commanders resent having the injured member removed from their unit. The Surgeon General does not think so. “The only reason a commander would retain someone is if they think they could better serve the interests of one of their members,” says Bernier, who is convinced that, particularly in severe cases, injured members can get more services in the JPSU.

“At Health Services, we provide medical officer advice in the Return to Work program that’s developed within the JPSU. We provide a nurse case manager who coordinates all clinical treatment and needs of that person. The JPSU has members from Veterans Affairs, representation from the insurance program, all of the elements that would provide support for that individual and their family. When people are assigned to the JPSU it’s because they can’t provide their military function, and primarily because they need additional support. At all costs, we want to retain that person, so we give them everything from the medical side and everything from vocational, everything that’s necessary to try and get that person back and be fit for duty.”

JPSU is the military unit to which CF members are assigned who have such significant medical employment limitations that they can't fulfil their military duties and/or need extensive medical care. “JPSU provides command, control, and administrative support to such patients, and serves as the focal point for global coordination of non-medical support provided by all elements supporting them (such as Veterans Affairs case managers, SISIP insurance, vocational training and rehabilitation, home modifications, and funding for transportation to medical appointments, and others)”, explains Bernier.

“CFHSG staff support the JPSU’s IPSCs in their support management function, but none of our staff belong to the JPSU. They remain exclusively part of their local CFHSG unit. Our Link Nurses maintain liaison between the military and civilian health systems, our Nurse Case Managers coordinate all health care for the patients (between primary care, medical specialists, etc), they and our Medical Officers (physicians) participate with IPSCs in developing the Return to Work plan for each patient, and our Field Ambulance Medical Link Teams fulfil some similar functions for Reservists dispersed away from where we have clinics.

Recovery
Asked how confident he is that people can recover enough from mental injuries to return to full duties, the commander of Health Services replied that “there are all kinds of illnesses where a certain number can be cured, a certain number can get better, and a certain number can’t be cured and will lead to terminal cases, and it’s the same thing with mental illnesses. As for PTSD, in general terms, about one-third will always struggle, about one-third will recover sufficiently to lead a normal life, and about one-third can fully recover and go into full remission.”

Dishearteningly, there may be a risk of relapse even among those who recover. Based on that risk, doctors at Health Services are aware that a high percentage of the people in the first two categories may no longer be “suitable” for military service and may never deploy again. Most of them will have to receive a medical discharge from the armed forces and their care will be transferred to Veterans Affairs.

A casualty with simulated injuries during an emergency response exercise, one of two held at CFB Borden annually. These exercises ­simulated different levels of emergency response including aircraft crash casualties. The life-like injuries were created by medical technicians from the Canadian Forces Health Services Training Centre. (Photo: Pte Alexandre Dutil, CFSTG Imagery Section)

BGen Bernier explains that, of the ones who recover sufficiently and can be fully fit to lead a very productive and happy life in civilian world, some may not be set for the armed forces because “the bar for occupational armed forces is typically much higher than it is in civilian occupations because of the extreme stresses that we need to keep being able to send our people into for military operations. Some may be able to fully recover from PTSD but may not personally be willing to take the risk of high stress in future deployments. Some do, we have had people in operations in Afghanistan who we assessed as being stable and fit enough to go outside the wire and fight in the war, and we’ve done that, but it’s an individual assessment on an individual case.”

Confidence plays a big part in those assessments. For instance, an individual who is fully free of symptomatology, fully in remission for their PTSD, may still feel they will experience vulnerability if they’re re-exposed to a high stress situation in military operations. In such cases “that individual, having been diagnosed with a mental health condition would be medically released from the armed forces if they are no longer willing or able to deploy.”

BGen Bernier wants to clarify that “medical releases as a result of mental health conditions doesn’t mean that the person isn’t fully back to normal, it just means that the risk of high stress military operations may be too great for them to remain in military operations.”

Families
Mental health injuries impact the entire family, and there are many civilian-run programs for military families. Is there an overlap between them and the various ­military programs?

“In all our interaction with civilian health organizations,” says Bernier, “we constantly encourage and seek to try to generate the maximum support for the health services to military families, we also recognize that the mental health of our troops is directly linked to the health and mental health of the family.”

Although prohibited from providing clinical care to family members unless it directly affects the health of an armed forces member, the Health Services Groups does have options. “In the Operational Trauma and Stress Support Centers, where we’re providing therapy to a Canadian Forces member both for the evaluation and assessment of their condition and their treatment, whenever there is a link to the family members we bring the whole family in. Our social workers provide help to the family – many of issues affecting our members are family or relationship centered, and so we involve the family members. The Road to Mental Readiness program has a family education component because we know the family has to deal with the stress too and, if one of our troops has a mental health condition, it will affect the family and that family will play a key role in getting that person to recognize the need for care and getting to care. The soldier’s condition will affect the family and the family’s condition will affect the soldier’s mental health.”

The Canadian Forces Member Assistance Program is available for CAF members and family members who are hesitant to present for care – they can anonymously call a number and get up to 8 or 10 mental health counseling sessions. “We certainly recognize that family stress does have an impact on the health of the Canadian Forces member and we provide certain services to assist in that regard.”

Funding and Commitment
Will funding for mental health programs fall off the table because symptoms may percolate for years before presenting? “No,” says BGen Bernier, “because of all the reasons I mentioned here today, and because of the political and senior military leaderships’ profound commitment to the health of the troops.” To illustrate that mental health commitment, at a time when the whole federal government is having to cut back, Bernier notes that “despite that overall pressure to reduce expenditures, the defense minister increased our mental health budget by 11.4 million [to almost] 50 million dollars going to mental health for our population. The per capita expenditure for mental health in the armed forces is now significantly greater than for any other health jurisdiction and that’s a demonstration of the understanding of their responsibility for looking after the health of their troops, the adverse impact of mental health at the individual level – and also on the armed forces at the operational level, in operational capability.”

Wrap Up
BGen Bernier subscribes to Field Marshal Bernard Montgomery’s assessment that morale is the most important factor for success in warfare. He also believes that recognition by political and military leadership and, possibly more importantly, by the Canadian public, of the sacrifices of military service and the unlimited liability they accept, is critical to every aspect of both military service and health rehabilitation.

During our interview, the Surgeon General shared a comment from General Peter Devlin, the outgoing commander of the army, who once told him that troops were much more willing to take personal risks to get the mission done on behalf of the defense of the country if they knew the healthcare they were going to get was top notch – so Bernier understands the direct effect on the will to fight and on commitment by warfighters. “If we’re going to order troops into combat and risk their lives,” says Bernier, “the Canadian public seems to accept that that means adequately resourcing them to remove any mitigatable risk – and that means prevention of injury and illness to the maximum extent possible, and where that fails, because of the realities of military operation, that they will get the best possible care for that sacrifice they have made for the rest of the country. So, as long as that public recognition is there, and certainly the recognition of the military and political leadership is there, then I have no concerns that our troops will be very well looked after.”

STIGMA... Is it REALLY Gone?
by Richard Bray

Many Canadian Forces personnel who need treatment for psychological injuries must first overcome the stigma associated with mental illness. In the First World War, acute symptoms of mental stress were called ‘shell shock’. In the Second World War, the condition was often termed ‘battle fatigue’. In those conflicts and others, mental injuries were often seen as signs of weakness and cowardice. Since the 1980s, Post Traumatic Stress Disorder has been used to describe the most acute response to operational stress. Veterans Affairs Canada describes PTSD as: “a psychological response to the experience of intense traumatic events, particularly those that threaten life. For military personnel, the trauma may relate to direct combat duties, being in a dangerous war zone, or taking part in peacekeeping missions under very difficult and stressful conditions.”

However, as recently as 2002, Canadian Forces Ombudsman André Marin testified before a House of Commons Committee that a widespread culture within the CF still believed those who suffer from PTSD are “malingerers, fakers or abusers of the system. As one soldier told us, ‘Many people within the CF believe that PTSD stands for People Trying to Screw the Department.’”

As LCol Suzanne Bailey of the Canadian Forces Directorate of Mental Health explained, “It has been said that when you come back to work after a heart attack, everyone thinks you are a hero. When you come back from depression, nobody knows what to say.” The stigma is very real, she says. “It is very debilitating and most people who are experiencing mental illness say that once they can manage the illness itself, it is the stigma that becomes the biggest battle for them.”

Working with the United States Marine Corps, the Canadian Forces developed the Mental Health Continuum Guide to help its members decide when to seek treatment for mental illness. The goal, LCol Bailey explains, is to overcome a tendency to ignore or conceal symptoms. “This four-colour model is much more realistic and essentially it says that mental health is a spectrum, it is a continuum, there is movement in both directions. Once you are ill, it does not mean you have to stay there. There are things you can do sometimes by yourself, sometimes with a professional clinician, but you can actually regain our health and go back to green.”